Healthcare Provider Details

I. General information

NPI: 1558943035
Provider Name (Legal Business Name): AVISTA PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3460 S REDWOOD RD STE 3
WEST VALLEY CITY UT
84119-3400
US

IV. Provider business mailing address

521 N 1030 E
PLEASANT GROVE UT
84062-4534
US

V. Phone/Fax

Practice location:
  • Phone: 509-818-9989
  • Fax:
Mailing address:
  • Phone: 509-818-9989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN DAX GERBER
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: DPT
Phone: 509-818-9989